The outcome of COVID‐19 patients in the intensive care unit in Sudan: A cross‐sectional study

Abstract Background and Aim A major outbreak of coronavirus spread all over the world and gave rise to high mortality rate and high admission rate to intensive care unit (ICU). This cohort study aims to assess the outcome of COVID‐19 patients in ICU and to investigate the factors associated with mortality. Method This is a multicentered retrospective cohort study that was conducted among confirmed cases of COVID‐19 patients, who were admitted to ICU in Sudan during March 2021. The data collection was done manually from the medical records of patients. Mortality rate and association and prediction of factors associated with mortality were obtained using Statistical Package for the Social Sciences software (SPSS) version 22. Results The mortality rate among patients in this study was 70%. Using the chi‐square test we found that age, needing intubation, developing Systemic inflammatory response syndrome, neurological complications, hematological complications, and cardiac complications have a significant association with the outcome. Conclusion Majority of COVID‐19 patients who were admitted to the ICU died. 55.8% of patients developed at least one complication during their stay in ICU. The age, the need for intubation, and developing of systematic inflammatory response syndrome (SIRS) are the factors that predict the mortality.

clinical manifestations of the disease range from asymptomatic infection to severe illness and even multiorgan failure and death. 6 Most studies have observed that poor outcomes are related to old age and the presence of comorbidities such as diabetes, hypertension, COPD, and other chronic diseases. 7,8 Populations having these factors are vulnerable to high hospitalization and ICU admission rates. 9 Those admitted to the ICU have an even higher rate of morbidity and mortality with the development of severe complications such as sepsis, acute respiratory distress syndrome, pulmonary embolism, multiple organ failure, neurological complications, and others, apart from the need for mechanical ventilation. 9,10 Comprehensive data of COVID-19 patients who are admitted to the ICU are needed to help healthcare providers to adopt appropriate management and interventions, to aim health authorities at national and international levels to develop various strategies that help to reduce mortality rates and combat this pandemic to save lives with limited resources. But unfortunately, in Sudan, COVID-19 data are limited, with no computerized medical records of patients making the issue of research difficult.
This cohort study aims to assess the outcome of COVID-19 patients in ICU and to investigate the factors associated with mortality.

| Study design and study population
This is a multicentered retrospective cohort study that was conducted among confirmed cases of COVID-19 patients, who were admitted to ICU in Sudan during march 2021.
The data were collected from medical records documented in ICU of both private and general hospitals in Sudan. Eight hospitals were included in this study, of which 6 hospitals were private. All patients aged 18 years and above, diagnosed with COVID-19 using polymerase chain reaction (PCR), and admitted to the ICU during the study period were included in this study. It is worth mentioning that hospitalized cases of COVID-19 who were not admitted to the ICU were not included in this study.
Unfortunately, during the study period, the COVID-19 vaccine was just introduced in Sudan so almost all of the patients were not vaccinated.

| Data collection
The collection of data was done manually from the medical records of patients using data sheets composed of three parts. The first part is about the patients' characteristics such as age, gender, comorbidities, duration of stay in ICU, the need for intubation, The second part is about the complication, and the third part is about the outcome.

| Data analysis
The Statistical Package for the Social Sciences software (SPSS) version 22 was used to analyze this data. Categorical data were reported as frequencies and percentages, while continuous data were not normally distributed and were reported as the median and interquartile range (IQR). Figures and tables were used to display the data.
To find the association between the categorical dependent and the independent variables, we used Pearson's chi-square test (two-sided asymptotic value obtained). Furthermore, we measured the prediction of the independent variables using binary logistic regression. Any p-value equals or less than 0.05 was considered to be statically significant for all analyses.

| Ethical considerations
Ethical approval was obtained from the ministry of health before starting the data collection. Participants' consent was obtained by contacting their families through their registered phone numbers.

| Demographics and clinical characteristics of patient
A total of 217 patients who met the selection criteria during the study period were included in this study. Most of those patients were male (64.5%), with a median age of 63 years (IQR: 57-66). 50.7% of them are above 65 years. Surprisingly, 77.4% of those patients are having at least one comorbidity, of which hypertension (55.3%) and diabetes (46.5%) are the most common chronic diseases existed among them.
Unfortunately, 55.8% of patients developed at least one complication during their stay in ICU, with systemic inflammatory response syndrome (SIRS) (48.4%) being the most common complication that happened among them (Table 2).

| Outcome and association
The mortality rate among patients in this study was 70%. only 30% of patients were discharged home well. Plotting factors in Tables 1 and 2 against the outcome, we found that age, needing intubation, developing SIRS, neurological complications, hematological complications, and cardiac complications have a significant association with the outcome using the chi-square test (Tables 1 and 2).

| Multivariate analysis
Intending to find which factor could predict mortality, we entered all the associated factors in Tables 1 and 2  ages ranged between 55 and 74 years. [11][12][13][14][15] Male participants in this study constituted 64.5% which is similar to the studies from Italy, Europe, Belgium, Sudan, and Mexico where more than 60% of the participants were males. [11][12][13]16,17 This might give rise to a hypothesis that males do get infected more with COVID-19 with a severe disease that renders them critically ill in the ICU, it is also consistent with the meta-analysis that showed male sex as a risk factor for death and ICU admission due to COVID-19 infection. 18 Yet, there is no statistical significance was found between the male gender and mortality in this study.
The median ICU admission duration was 11 days (IQR: 9-14), which is similar to other reviewed studies where median ICU stay ranged between 6 and 12 days regardless of the mortality rate.
The mortality rate in this cohort was 70% which is higher than

| The pattern of complications
The most common complication reported after ICU admission in this cohort was SIRS that 48% of patients developed. This high percentage may be attributed to many factors including the immunological response to the COVID-19 virus 22 and ICU-related infections. 23 ICU admission itself, regardless of the illness, was found to be associated with the development of sepsis in many studies. 23 Ventilation-associated pneumonia reported in ICU critically ill patients is highly associated with the development of SIRS. 24 Hence, the development of this syndrome could be multifactorial.
In this cohort, only 8% of patients developed neurological complications, this percentage is much lower when compared to the study conducted in the United Kingdom where 62% of participants developed neurological events both at presentation and during the hospital stay. 25 Moreover, a global cohort study of the incidence of neurological complications among COVID-19 patients revealed a prevalence of about 80% among them. 26 Hematological complications occurred in 13.4% of the patients, while 7.8% developed cardiac complications.
These percentages are similar to other studies from the United States and Europe. 9,12 The later complications are considered low and even significantly lower when compared with those who developed SIRS. and Belgium (Odds OR: 1.07). 13,16 The development of SIRS is a predictor of mortality among COVID-19 patients in this study, but this was not mentioned in other reviewed studies. Nevertheless, an increase or decrease in white blood cell count, which is a component of SIRS, was a predictor for mortality in studies from eastern Sudan and Mexico. 16,17 The usage of mechanical ventilation predicted higher mortality in this cohort. Although this intervention aims to save lives, it was found to be associated with mortality in other countries, the systematic review and meta-analysis of the factors associated with mortality in